Medical and Dental History Form Medical and Dental History Form Surname * First name * Address * Phone * Please include at least one of the following (Home xxxx xxxx Work xxxx xxxx Mobile xxxx xxx xxx) Email * Date of birth (dd/mm/yyyy) * How did you hear about our practice? Contact in case of emergency * Phone * Are you of Aboriginal and/or Torres Strait Islander origin? No Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander Prefer not to say Do you have any wishes or problems that you have concerning your teeth and mouth (pain, bleeding gums, discoloured teeth)? Do you have, or ever had, any of the following medical conditions? Tip: You can use the tab key on a desktop keyboard to move to the next field and the space key to make a selection. Steroid therapy * No Yes Kidney disease * No Yes Prosthetic implant e.g. artificial hip * No Yes Rheumatic fever * No Yes Excessive bleeding * No Yes Epilepsy * No Yes Heart valve disorder * No Yes Asthma * No Yes Stomach digestive condition * No Yes Heart murmur * No Yes Nervous condition * No Yes Anemia * No Yes Cardiac pacemaker * No Yes Tuberculosis * No Yes Hepatitis * No A B C Heart complaint * No Yes Thyroid disease * No Yes Contact with HIV/AIDS * No HIV Aids Stroke * No Yes Diabetes * No Yes Emphysema / bronchitis * No Yes Radiation therapy * No Yes High blood pressure * No Yes Transplanted organ or marrow * No Yes Leukemia * No Yes Low blood pressure * No Yes Any other conditions * Please write "NA" if not applicable Insurance DVA gold card Yes No DVA white card Yes No DVA no DVA expiry date mm/yyyy DVA specific condition CBDS Yes No Private health insurer Private health fund membership no Private health reference no Medicare card no Medicare reference no Name as it appears Medicare expiry date mm/yyyy Additional information Tip: You can use the tab key on a desktop keyboard to move to the next field and the space key to make a selection. Are you being treated by a doctor at present? * No Yes Details * Are you taking any tablets or medicines? * No Yes Details * Do you require antibiotic cover for dental treatment? * No Yes Details * Have you had an abnormal reaction to local anesthetic? * No Yes Details * Do you smoke? * No Yes Details * Are you pregnant or trying to fall pregnant? * No Yes I'm male Details * Who is your General Medical Practitioner? * GP Phone * Please list any known allergies * Please write "NA" if not applicable Do you have confidential medical information that you do not wish to write down and would prefer to speak to the dentist about? * Yes No Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank.
